Case Study for Differential Diagnosis Assignment
Maternal History: This is a 29 yo Gravida 1, Para 0 mother delivering at 39 3/7wks gestation.
Maternal Labs include: Bl. Type A (-), Rubella immune, HepBsAg (-)/ GBS (-)/ Rapid plasma regain (RPR) non-reactive/HIV (-)/ GC & Chlamydia (-)/ platelet count 256/ glucola 111.
Maternal history complicated by: 1) chronic Percocet use for back pain secondary to car accident 1 ½ years prior, 2) variable decelerations with labor, 3) placement of fetal scalp electrode, 4) worsening pre-eclampsia (3+ urine protein), 5) Chronic hypertension, 6) ROM x 18 hours PTD
Maternal medications: 1) Percocet use in pregnancy, 2) Pitocin, 3) epidural, 4) Labetalol, 5) Rhogam, 6) pre-natal vitamins, 7) Nubian in labor
In labor there were no concerns for clinical chorioamnionitis, uterine tenderness, vaginal discharge, or maternal fever. Variable decelerations were monitored with a fetal scalp electrode. The infant was delivered vaginally through clear fluid under epidural anesthesia. The infant presented with a nuchal cord x1 that was reduced on the perineum. The infant emerged with good tone and a spontaneous cry and was transferred to the warmer, was dried/stimulated, mouth and nose were bulb suctioned. The infant did not have any grunting, flaring, or retracting and did not require oxygen for resuscitation. Pulse oximeter reading 97% in RA.
By 10 minutes of life the infant was noted to have extreme jitteriness and tremors of all extremities that stops easily when the extremity is held. Birth weight 3.215kg AGA for a term infant.
PE: was otherwise unremarkable.
List diagnoses in order of most likely to least likely from the maternal history provided to explain the presenting symptom. Your textbooks will be needed for this exercise, include references (in APA style, please).
Discussion of maternal conditions that place the fetus/neonate at risk for health disruptions is concise and comprehensive – 40%
List of differential diagnoses was inclusive – 40%
Presentation was succinct in presenting outline of maternal conditions and potential differential diagnoses for the neonate – 20%
– Write a scriipt of below the assignment that you will use to reflect on the assignment.
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